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Division of Distance and Distributed Learning

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  1. Division of Distance and Distributed Learning

  2. DETERMINANTS OF HEALTH • Public Health & the socio-political milieu • Population interventions • Health, illness & disease • Measuring health

  3. BASIC QUESTIONS • What is health? • How can health status and quality of life be measured? • What do we know about health from our experiences in the last century? • What factors influence health and illness? • What do current measures tell us about the health status and quality of life of Americans at the beginning of the 21st century? • How can this information be used to develop effective public policy and interventions?

  4. LIFE IN THE U.S. IN 1900 • Crude mortality rate – 1,700/100,000 pop. • Life expectancy – 47 years • Life expectancy at 65 – 12 years • Health care was of questionable benefit

  5. LIFE IN U.S. IN 2000 • Crude mortality 850/100,000 pop. • Age adjusted mortality fell even more • 470/100,000 • Infant mortality rates fell 95 percent • Life expectancy -- 77 years • Life expectancy at 65—18 years

  6. LEADING CAUSES OF DEATH, 1900*

  7. LEADING CAUSES OF DEATH, 1997

  8. WHAT HAS BEEN GOING ON?

  9. WHAT IS HEALTH? • Historically defined as lack of illness or injury • WHO—”state of complete physical, mental and social well-being, not merely the absence of disease or infirmity” • How do health and illness or injury relate? • WHO ’78—socially and economically productive lives

  10. DEFINING HEALTH (1) “A state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity.” (WHO ’46)

  11. DEFINING HEALTH (2) “Health is…the extent to which an individual or a group is able, on the one hand, to realize aspirations and satisfy needs; and , on the other hand, to change or cope with the environment” (WHO ’84)

  12. DEFINING HEALTH (3) “Health is a state characterized by anatomic integrity, ability to perform personally valued family, work and community roles; ability to deal with physical, biologic, and social stress; a feeling of well-being; and freedom from the risk of disease and untimely death” (Stokes, ’82)

  13. MEASURING HEALTH • Mortality-based measures • Crude, age adjusted mortality rates • Years Potential Life Lost • Non-mortality-based measures • Morbidity • Disability • Quality

  14. MEASURING HEALTH MORTALITY • Crude mortality • Adjusted mortality • Life expectancy • Years of Potential Life Lost (YPLL)

  15. Age-Adjusted YPLL Cancer Heart disease Injury Suicide Number of Deaths 1. Heart disease 2. Cancer 4. Injury 10. Suicide YPLL ILLUSTRATION

  16. CAUSES OF MORTALITY

  17. MORBIDITY-RELATED INDICATORS • Disability-free life years or years of healthy life (YHL) • Functional limitations • Days of lost work • Days of restricted activity • Activities requiring assistance • Perceived health status (Excellent, VG, Good, Poor, Fair)

  18. What does it all mean? • Healthier, live longer, less likely to be injured or in ill health • Spend nearly 17% of GDP on health care • More than all other industrialized countries • Yet below average on health status • By all estimates, falling way short of our potential

  19. WHAT ARE THE DETERMINANTS OF HEALTH? Why is it important that we understand the determinants?

  20. DETERMINANTS OF HEALTH

  21. MODELING HEALTH PROBLEMS (1) HEALTH PROBLEM DIRECT CONTRIBUTING FACTOR DETERMINANT INDIRECT CONTRIBUTING FACTOR

  22. MODELING HEALTH PROBLEMS (2) DIRECT Lack of prenatal care Low maternal Weight gain PROBLEM Neonatal Mortality DETERMINANT LBW below 2500g INDIRECT No transportation No childcare

  23. RISK FACTORS AND DETERMINANTS

  24. HEALTHY PEOPLE 2010 • Goals • Increase quality and years of healthy life • Eliminate health disparities • Focus areas (467 objectives, 28 priority areas) • Leading indicators for each areas • Targets (specific and quantitative)

  25. GLOBAL HEALTH FACTORS • POLLUTION (e.g., greenhouse effect and global warming) • POPULATION (population burden on finite resources) • POVERTY (always the genesis of illness and epidemics)

  26. HEALTH DISPARITIES

  27. AGE ADJUSTED DEATH RATES

  28. OBESITY BY AGE AND GENDER

  29. OBESITY PERCENTAGE

  30. LACK OF HEALTH INSURANCE

  31. EQUITY OR JUSTICE (Aday) • Substantive equity -- minimization of health outcome disparities among subgroups in population • Procedural equity -- assuring that the structures and processes associated with the provision of health care are fair

  32. SOCIAL DETERMINANTS OF HEALTH • SES • Educational attainment • Income and Occupation • Zip code predictive of health status

  33. SES AND HEALTH (Lynch and Kaplan)

  34. INFANT MORTALITY FOR MOTHERS >20 AND MOTHER’S EDUCATION(per 1K live births, Health, USA, 2001)

  35. CHILDREN <6 WITH NO OFFICE OR CLINIC VISIT IN LAST 12 MONTHS(%, Health, USA, 2001)

  36. SES and Health Indicators ( %, Health USA, 2001)

  37. MALE AGE-ADJUSTED MORTALITY RATES (25-64) AND EDUCATION (per 100K, Health, USA, 2001)

  38. RACE, ETHNICITY AND HEALTH IN THE UNITED STATES

  39. YEARS OF HEALTHY LIFE

  40. RACE AND HEALTH INDICATORS (%, Health, USA, 2001)

  41. HEALTH SYSTEM USE BY YOUTH UNDER 18, 1999(%, Health, USA, 2001)

  42. MAMMOGRAPHY FOR WOMEN 50-64 YEARS OLD (%, Health, USA, 2001)

  43. AGE-ADJUSTED DEATH RATES FOR BLACKS AND WHITES FOR SELECTED CONDITIONS (per 100k, Health, USA, 2001)

  44. Racial/Ethnic Disparities in Health • Despite targeting of these disparities • They persist or have worsened • Simple health effects of discrimination now being examined directly • Minorities much more likely to be uninsured • Link between racial and economic disparities creates double jeopardy

  45. DETERMINANTS OF HEALTH

  46. Improve data sources Use available data Disseminate findings Build on existing initiatives Create cross-sectoral alliances (political, professional, community) Health dept. take the lead in forming task forces Highlight human potential Use media creatively Attract new funders Healthy people needs targets for health disparity reduction MOSS’S ACTION AGENDA AGAINST INEQUALITY

  47. FACTORS THAT INFLUENCE US POPULATION HEALTH • Societal Norms • Balance economic, political and social priorities • Tensions between rights and responsibilities (individual freedom vs. community social needs, regulation and free enterprise) • Vibrant economy vs. environmental health • Clinical care and research vs. population health and disease prevention

  48. ECOLOGICAL INFLUENCES ON HEALTH • Characteristics of places important • Wealth of community important • But huge disparities in income in US • Economic inequality hypothesized to have impact on individual health status independent of individual income in absolute sense • We fail to buffer inequities in income distribution w/ strong social services

  49. US HEALTH POLICY • Disproportionate preeminence given to the individual over the population health approach • Greater emphasis on biomedical over prevention research, and on medical care over preventive services • Neglect of the evidence (and of the need for more empirical research) about the multiple factors that shape individual and population health, from the political to the environmental, from the social to the behavioral.

  50. POPULATION PERSPECTIVE • Three features of population strategy • Disease risk is viewed as continuous data • Only small percentage of the population is at extremely high or extremely low risk • Individual risk cannot be considered in isolation from risk to the larger population